Atrial flutter can cause false-positive ***ACUTE MI SUSPECTED*** interpretive statements

I first heard about this issue a couple of years ago in a webinar at the D2B Alliance website. Since then I have seen it several times in my own EMS system.

I also mentioned it when I commented on:

Review of Factors Associated With False-Positive Emergency Medical Services Triage for Percutaneous Coronary Intervention

According to that study the most common factors associated with false positives statements were:

  • A specific brand of one of three monitors used in the system
  • Sinus tachycardia
  • Missing lead recording on 12-lead printout
  • Atrial fibrillation
  • Female gender
  • Poor ECG baseline
  • A discussion ensues during

The authors make this important statement:

“Poor ECG baseline and failure to record all 12 leads for machine algorithm interpretation are false-positive associated variables that can be addressed by improved quality in field acquisition of 12-leads.”

It can’t be said often enough! That’s why I’m always harping on achieving excellent data quality!

The authors continue:

“Variables more difficult to address are sinus tachycardia and atrial fibrillation, which had a tendency to be wrongly interpreted by machine algorithm as acute MI.”

In response to that statement I made this comment:

“It would be interesting to know if they are including atrial flutter in with atrial fibrillation. Either way the message is clear. The specificity of the computerized interpretive algorithms is highest when a tachycardia is not present.”

The reason I questioned whether or not atrial flutter was included with atrial fibrillation is simple. Many times I have seen atrial flutter trigger a false-positive ***ACUTE MI SUSPECTED*** message on the LP12 but I can’t think of a time atrial fibrillation cause a false-positive statement (when poor data quality was not present).

Consider these cases that occurred in the past week.

Case #1

In this case the paramedic immediately realized the ***ACUTE MI SUSPECTED*** message was being caused by underlying atrial flutter. A “STEMI Alert” was not called from the field and the patient was not sent to the cath lab.

Case #2

This case was a little more difficult because 2:1 atrial flutter more difficult to recognize than 4:1 atrial flutter. It also must be said that this patient was “sicker” and presented very much like ACS. A “STEMI Alert” was called from the field and the patient ended up in the cath lab. No significant lesions were noted with angiography.

The point isn’t to blame the paramedic from the second case. A board certified emergency physician and a cardiologist both had to agree that this patient needed emergent angiography.

It’s easy to criticize individual paramedics especially when they’re from other EMS systems. What’s hard is to create quality improvement feedback mechanisms so that every call can be a learning opportunity.

There are two kinds of EMS systems in this world: those that make mistakes and those that have no idea whether or not they make mistakes (unless they receive a complaint).

Strive to be the former because anyone can be the latter.

5 Comments

  • Christopher says:

    Second ECG is tough! Rate and p-axis in II/III can lead you to 2:1 flutter. Also the T-waves are certainly strange looking. I think the only thing holding me back from a STEMI call is the rate on that one.

  • Christopher says:

    Another thing that a-fib/flutter can mess with is synchronized cardioversion. Resuscitation recently had a case where an ED used a Philips MRx set to sync through the pads and the R-wave detection kept picking up the fib/flutter waves as well, delivered a shock, caused R-on-T, v-fib…and thankfully a successful resuscitation.

    Sodeck GH, Huber J, Stöllberger C. Electrical cardioversion – misinterpretation of the R-wave. Resuscitation. 2011 Jan;82(1):135-6.

  • Mike Sherriff says:

    I too have had 2:1 A-Flutter read incorrectly as STEMI, on a Zoll.

  • speaking of a-flutter, when i review ekgs i’ve noticed the LP12s love to interpret VT as a-flutter.

  • Banery says:

    There always you want to a 740 problem during the installation.
    The MAC compatibility means that that Dub Turbo software
    can be powered by an iPad.

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Comments
know it all parapup
83 Year Old Male: Shortness of Breath
@ Kyle I would question your authority to call out people for not having a license or being a know it all parapup when your tx basically entails "call medical control." I think we can both agree that his cardiac output is not great at all. I assume your reluctance to give him any other…
2014-10-30 20:26:11
Kyle
83 Year Old Male: Shortness of Breath
Well st elevation in avr and v1 associated with anterior and lateral depression would call for possible posterior wall MI. 15 lead would be in order. Also check all the leads for appropriate placing. If v7, v8, and v9 show the elevation i would treat as a STEMI per my protocol. Asprin only until medical…
2014-10-30 18:14:05
Tim
The most awesome STEMI test on the internet!
Thanks for the app. It made me think about all that one may see in the field. The only problem was I never got a score or saw the results of how I did other than saying I had completed the test. Anyway a great way to get the old brain working.
2014-10-30 13:14:27
Brian
83 Year Old Male: Shortness of Breath
I mostly agree with dustin. I believe this is may be an isolated posterior MI. The R wave in V2 points to it being a posterior MI. otherwise it is a 1st degree av block with a LAHB. I am somewhat concerned with the concordant t segment depression noted and in fact if you were…
2014-10-30 04:22:44
Karl Brennan
Understanding Amiodarone
Great article , however in VF caused by hyperkalemia it should be avoided along with lidocaine , Since it shuts down the K channels, the eiteiology of the arrest hyper K, K channels are needed to exchange K in the cell. Calcium , Bicarbonate, dextrose and insulin should be used to decrease K levels along…
2014-10-30 03:04:45

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